Thursday, March 28, 2013

Saturday was the Affordable Care Act’s third birthday, but you might have missed it for all of the (lack of) attention it received. Sure, there was the usual back and forth from the law’s supporters and opponents, but almost nothing that provided any new insights.

Supporters, such as the liberal New York Times editorial page, marked the ACA’s anniversary by touting the tens of millions already being helped by the law, from seniors on Medicare getting preventive services at no cost to them, to children with pre-existing conditions being able to get affordable coverage—the first steps on the road to expanding coverage next year to as many as 30 million uninsured persons (including 535,000 uninsured veterans according to a new study) while providing new benefits and consumer protections to everyone.

Opponents such as the conservative Heritage foundation, marked ObamaCare’s anniversary by charging that it is causing higher premiums, putting more people out of work, leading to a loss of employer coverage, and making it more difficult for seniors to access Medicare-covered services.

Because the charges and counter charges were mostly a repeat of the same old tired talking points we have been hearing for three years, is it any wonder that much the public tuned the whole thing out?
Meanwhile, a new poll shows that the public remains ambivalent about the law and perhaps even more confused than ever. According to the Kaiser Family Foundation’s well-respected health tracking poll, “a majority of Americans are unsure how the law will impact them, and few are paying attention to the details of state‐level decisions about implementation. Though opinion on the law overall remains nearly evenly divided, opponents’ attacks seem to have taken a toll on the public’s expectations, and Americans are now more likely to think the law will make things worse rather than better for their own families. While most of the law’s individual provisions remain popular, many of the most well‐liked elements are the least well‐known among the public. Public knowledge of the ACA’s provisions has not increased since 2010, and awareness of some key provisions has declined somewhat since the law’s passage when media attention was at its height.”

As Mick Jagger sang, “it’s enough to make a grown man cry!”

But let’s put aside the political talking points for a moment, and instead look at some hard truths about ObamaCare’s present and future:

1. The law already is helping many millions of people—that’s a fact, not a talking point. For the most part, the people being helped so far are mostly those who already had health insurance coverage (no-cost preventive services for seniors, rebates if your insurance company spends too much on profit and administration rather than patient care, elimination of life-time limits on coverage) while helping relatively small pockets of people who in the past had trouble getting coverage (e.g. children and some adults with pre-existing conditions, and young adults). The law also has increased Medicare and Medicaid payments to primary care physicians, provided scholarships and loan forgiveness for thousands of them and increased access to underserved communities through the National Health Services Corps. The Kaiser Family Foundation has an excellent three-year anniversary summary of who has benefited so far and the progress being made in preparing for the next steps. These gains are nothing to sneeze about, but they are just the opening acts to the huge changes that are supposed to take place in a little over nine months, when the ACA’s biggest coverage expansions and full gamut of health insurance regulations are scheduled to take place.

2. The next act—expanding coverage to up to 30 million uninsured persons and mandating minimum levels of health insurance benefits and new consumer protections for everyone-- will be highly disruptive to the current system, and as a result some things will go right, some things will go wrong, some will pay more, some will pay less. But why should this surprise anyone?

Did anyone really think we could transition from the current system, where tens of millions are uninsured, where many millions more have inadequate insurance and consumer protections from insurance practices that put them at risk of losing coverage, to one where almost all legal residents will have access to guaranteed, subsidized minimum benefits that can’t be taken away when you get sick, without it being highly disruptive? Changing the status quo is supposed to be disruptive.

Did anyone think you can provide coverage to people who don’t have health insurance, especially those who are older and sicker, without some people (mainly the healthy young and wealthy of all ages) paying more through higher taxes and premiums? This is the way risk-sharing and pooling is supposed to work!

(About those premium increases for some people, by the way: keep in mind that this isn’t a case of premiums going up for the same old insurance you had before, it is premiums going up for new and improved insurance offered on the individual insurance market. An analogy: when the federal government required all new cars to have seat belts, air bags, and safer crash protection, these increased costs were passed on to consumers through higher prices, but most of us would agree it was worth it, because with these features, we are less likely to die or become hurt in car crash! The same is true for health insurance: the insurance we will buy next year will have standardized benefits and consumer protections that will help ensure that we all have better access to health coverage with the benefits we need to help keep us alive and well, so of course we may have to pay a bit more for it. But also keep in mind that under the ACA, the premium charged isn’t the same as what the insurance will actually cost you, because anyone with an income up to 400% of the federal poverty level--about $94,000 for a family of four--will be eligible for subsidies to help keep the cost down).

The social contract underlying all of this, of course, is that someday it will be me, someday it will be you, who will become older and sicker, and we all benefit from having a system that spreads risks and costs more equally over our lifetimes so that health insurance and healthcare are there for us when we need it most, at a price we can afford at that time.

3. The biggest practical challenge facing Obamacare is that the federal governmenthas too little control over what happens next. Yeah, I know it is a staple of conservative critiques of the law that it is a big (federal) government take-over of healthcare, but from the very beginning, the ACA was classic example of U.S. federalism—the federal government would provide most of the money and establish the ground rules, while the states would create the structures to implement most of it. So, as the law was written, the states were supposed to be the ones who would set up the marketplaces (exchanges) by which eligible persons would be able to buy a qualified and federally-subsidized health insurance coverage. The states were supposed to be the ones to expand Medicaid to the poor- and near- poor, paid for almost entirely by the federal government. (Originally, the Medicaid expansion was for all intents mandatory, because states could have lost their current Medicaid funds if they didn’t go along—but the Supreme Court decided in 2011 that punishing states for not going along was unconstitutional, making the Medicaid expansion a totally voluntary one for the states). Because Republican governors and legislatures in most states are continuing to resist Obamacare, both for political (ideological opposition and a desire to see it fail, see below) and practical reasons (uncertainty about how much it will cost them), most states have opted-out of setting up the health insurance exchanges and only half have agreed to the Medicaid expansion.

In the immediate future, the federal government may (on paper, at least) actually have some more control over the health insurance industry than originally anticipated by the ACA’s framers, because it will run the health insurance marketplaces (exchanges) for the dozens of states that opted-out. This raises another concern though: will the federal government really be able to carry it out, especially since Congress has not given the administration any additional money to help pay the increased costs it will incur for the federal exchange and the agency responsible for the program has lost billions of dollars in funding because of sequestration? The administration says it will be ready to operate an exchange in every state that has opted-out—but this is hardly a sure thing.

The key point though is that under the ACA, the federal government does not have the power turn a switch to make the program work the way it wants it to (like it can with Medicare); instead, it must rely on the states, including GOP-led states that in many cases are going to do everything they can to make sure it doesn’t succeed.

4. This brings me to the greatest political challenge facing the ACA, which is the unrelenting effort by GOP opponents to try to make sure it fails. It is no secret that Republicans will continue to try to limit funding for Obamacare’s implementation. They will push for votes to remove the tax revenue that the government needs to fund it. They will point to any problems that can be pinned on the law (e.g. higher premiums for some people, the confusion that will take place as new insurance options are rolled out next year) as evidence that the law isn’t working. They and their allies will continue to go to court to try to get it overturned. Most importantly, they will count on state resistance to the law (see #3 above) to make the law’s “failure” become a self-fulfilling reality. This, they hope, will lead to an “I told you so moment” and widespread public disaffection with Obamacare.

As the Washington Post’s Ezra Klein notes, “ceaseless efforts Republicans have made to attack the law publicly, impede it procedurally and defund it legislatively. Implementation of a law of this size would always be difficult. But it will be far harder with Republican governors refusing to help and Republican legislators viewing each and every tough problem as an opportunity to chip away at the legislation.” But this will not result in repeal, he believes. “Obamacare can have a hard implementation in 2014, but President Obama isn’t going to repeal it or even lose reelection over it (though congressional Democrats might). And by 2015, it will be insuring tens of millions of people, the health-care industry will have adapted and many businesses and ordinary Americans will be using the exchanges. At that point, no one is going to repeal it.”

So to summarize, an honest assessment of Obamacare on its third anniversary would acknowledge that it already is helping tens of millions of people. It would also acknowledge that the next steps—expanding coverage to up to 30 million uninsured persons and providing better benefits and consumer protections to everyone —will be highly disruptive, but that this shouldn’t surprise anyone, it was supposed to be disruptive. It would acknowledge that some things will go right and some things will go wrong as a result. It would note that the states have a critically important role in making all of this work but acknowledge that many GOP-led states will be doing everything possible to make Obamacare fail. It would acknowledge the political reality is that congressional Republicans have no intention of calling a ceasefire in their efforts to make sure that Obamacare’s implementation does not go well, hoping that if the implementation is messy they can decisively turn public opinion against it.

It would also acknowledge that in the end, Obamacare is not likely to go away, and somehow or another, bumps and all, it likely will get us to a better place than today, a health care system where nearly all will have access to better and more affordable health insurance coverage. But getting from here to there isn’t necessarily going to be pretty.

Today’s question: What do you think of my analysis of the “hard truths” about Obamacare on its third anniversary?

Tuesday, March 19, 2013

“Physicians care more about their pocketbooks than taking care of patients. They are self-interested and overpaid. They want to control everything. They don’t know what life is like in the real world of patients.”

By now, I am sure that physician readers of this blog can feel their blood boiling, for good reason. Why would I, as the principal staff advocate for internal medicine physicians, put such pernicious, unfair, inaccurate quotes in my blog?

You would be right to be angry at me—if I believed any of the above, but I don’t. I work for doctors because I believe in doctors. I believe that with very few exceptions, physicians are motivated by a compassionate commitment to applying their skills and training to improve the health of their patients and the American people. And when it comes to physician advocacy in public policy arena, I believe that the vast majority of them take stances that they believe to be in the best interests of patient care, even though they may not agree among themselves on the best course of action.
So why would I start this article with made-up quotes (although you can find many people who say the same) that cast aspersions on the medical profession? To make the point that broadly labeling a profession or occupation as consisting of people who are unethical, self-interested, controlling, over-paid, and out-of-touch is simply wrong—on the facts, but also by any sense of objectivity and fairness. Casting aspersions, after all, means making “a false or misleading charge meant to harm someone's reputation, cast aspersions on her integrity” or “the act of making such a charge: defamation.”

But there is one group of our fellow Americans—almost two million of them, by the way—that are regularly defamed in the political arena: people who work for the federal government. People I know, people who are my friends, people who I interact with every day on behalf of the American College of Physicians, people that many of you know—most of whom live and work outside of Washington, DC. (Very early in my career, I was one of them, employed by a federal agency that dispensed higher education grants, and before then, as an unpaid intern for a member of Congress).

Here is what I know about them, and maybe you don’t, or maybe you do. Most of them work extraordinarily long hours, longer than many I know in the private sector. They haven’t had a raise in three years yet their productivity would put many private sector employees to shame.

Most are motivated by a desire to serve the public—that is why they chose careers in public service, rather than Wall Street. Many are highly educated, but many are also working class people who are doing the unseen work of keeping things running. Many have advanced degrees and years of experience that would have allowed them to cash in long ago to make more money in the private sector, but they don’t, because they have a higher calling than that. Many of them have chosen careers that potentially put them in harm’s way—Soldiers, Sailors, Airmen, Marines; and people like my sister, a foreign service officer who represents U.S. interests in other countries; and FBI agents, Capitol Hill and Park Service police, federal marshals, and many more who work in law enforcement.

Most federal employees are crammed into small offices and cubicles that from all appearances haven’t been upgraded since the 1950s. Instead of state-of-the art technologies, most are stuck with out-of-date computers and cell phones (past generation Blackberries, no IPhones for them!). They are at the whim of whatever Congress decides to do, or not do, to enact a federal budget, with the seemingly constant risk of government shut-downs (read, lay-offs), and now, sequestration pay cuts. They expected to do their jobs even as travel budgets are slashed, hiring freezes imposed, and technology upgrades cancelled because of funding cuts.

They are people like my friends in the Government Accountability Office, whose jobs are to investigate federal spending programs (on behalf of Congress) to ensure that the money is spent wisely and effectively. They are people who make sure all of those millions of Medicare and Social Security checks go out every week. They are people like my friend at Treasury who tracks money laundering by terrorists and drug kingpins. They are the federal agency employees whose jobs are to turn laws passed by Congress into workable regulations and policies—just think of all the employees of the Center for Medicare and Medicaid Services who are working over-time to try to implement the Affordable Care Act on time and effectively, to ensure that it meets its goal of expanding access to affordable coverage. They didn’t write the law, but they have to make it work.

They are people like my brother-in-law, who works for probably the most loathed agency, the IRS—but without which, we wouldn’t have the resources required to do everything the federal government does, from keeping the elderly out of poverty to keeping us safe to providing financial assistance to the poor to paying for physicians’ graduate medical education, whatever we the public have asked the federal government to do through laws duly enacted by the Congress we elect. They are people like a former ACP colleague of mine and long-term friend who now works as a Republican staffer on Capitol Hill, assigned with such seemingly insurmountable jobs as figuring out a way to eliminate Medicare’s SGR formula and create new and more effective payment systems!

They are people like the ACP physician members who work in CMS and other federal agencies, guiding research on health care disparities and access (Carolyn Clancy, MD who is the outgoing director, Agency for Healthcare Research and Quality) and federal funding to improve health care payment and delivery systems (Rich Baron, MD, who left private practice to work in CMS’s Center for Medicare and Medicaid Innovation and is now leaving to become CEO of the American Board of Internal Medicine). People like former CMS administrator (and pediatrician) Don Berwick, who brought a refreshing and passionate voice to the agency on always putting patients first. This is how Dr. Berwick describes his CMS colleagues:

“The time at CMS has been a privilege. I got the chance to work with thousands of career public servants, and to learn how much these people do for us all, unsung and too often unappreciated. These are the people who translate laws into regulations and regulations into deeds. In CMS these are the people who keep the lights on – they see that providers get paid, they protect the public trust, they help the most vulnerable people in America, and make sure that they get the care they need.”

Yet as a class, federal employers are castigated, repeatedly, inaccurately, and unfairly, often by politicians (who themselves are federal employees)! Politicians who call federal employees “faceless bureaucrats” even though they know that federal employees have names and faces--and by law are held to very high levels of accountability and transparency for their work.

But it is not just the politicians who castigate federal employees: polls show that much of the public views them as being "lazy, overpaid, and incompetent, among other adjectives.” A recent poll even found that a majority consider federal employees to be “corrupt” even though objective studies show that the public sector in the United States is rated as among the “cleanest” (least corrupt) in the world. And, to the extent that there is a risk of public sector corruption in the U.S, it is more likely to be in state governments than the federal government.

And now, because of Congress’ failure to reach a thoughtful deficit reduction package, we are stuck with across-the-board cuts that will furlough (mandatory unpaid time off) as many as a million federal employees—the equivalent of a 20% pay cut for those affected. Physicians rightly are crying foul over a scheduled 20% cut in Medicare doctor pay, but where is their sympathy for federal employees taking a comparable hit?

It is one thing to criticize federal government policies that you don’t agree with, to try to get those policies changed, and to elect different people to office—this is the essence of democracy. And for sure, the partisan gridlock in Washington is a sound reason to feel disconnected, even disgusted by the state of politics and governance today. But it is another thing to defame the hard-working, conscientious, honest, and public-spirited federal employees who, after all, are working for us.

Yes, there are a few bad actors in any line of work, whether it is an indifferent public employee or an unethical physician. But it is wrong to cast aspersions on dedicated and public-spirited physicians because of the ethical failings of a few, just as it is wrong to cast aspersions on dedicated and public-spirited federal employees because you might have had a bad experience with a few of them. The fact is that physicians and public sector employees have one important thing in common: they have chosen public service careers, and are doing the best they can in exceedingly difficult circumstances. But physicians, unlike federal employees, at least have the comfort of extremely high ratings from the public.

Today’s question: Do you agree with me that it is wrong to cast aspersions on all federal employees?

Friday, March 15, 2013

Veteran readers of this blog know that I descend from a decidedly Irish heritage. My dear departed father, Jack Doherty, was born in a primitive thatched cottage in Drumshambo, Ireland, in County Leitrim, historically one of the poorest counties in Ireland. He emigrated to the United States at the age of 10 with my grandmother, Eliza (Elsie) Doherty, joining his father, who had emigrated several years earlier. He later made his living working behind (and owning) Doherty’s Bar in Woodside, Queens, New York, an establishment opened by his father Tom Doherty. When I was in college, I worked behind Doherty’s Bar, the third generation of Doherty’s “behind the stick” as the old-timer patrons put it. (This is one thing I have in common with Speaker of the House John Boehner—we are both SOB’s, or sons of bartenders.) Later on, my Dad went back to school to get his B.A and then a Masters in education, sold the bar, and became a high school teacher at an inner-city school in Brooklyn, New York.

So you can imagine that Saint Patrick’s Day is an important day on my calendar. Like all good Irish (Americans), it is a day for story-telling, enjoying “fine” Irish cuisine, and um . . . imbibing in some of the other pleasures associated with being Irish. One tradition I particularly enjoy is the distinct form of humorous poetry known as limericks, named after the famous city in Ireland, although some engage in the heresy of saying that the English invented it!

In honor of Saint Patrick’s Day weekend, I have penned a few political limericks for your enjoyment (I hope). (Advice, they may read better after you’ve had a few!)

I am so sick of the Medicare SGR,Makes me want to escape to a barI'd prefer to drinkRather than thinkAbout how Congress has denied care to Grandma.

It really isn't fairHow critics attack ObamacareDeath panels are a lieThey won't send grandma to dieScaring seniors is more than I can bear

Do you share my sense of frustration?At Congress sticking us with sequestration?Closing White House tours is cheap,Long lines at airports make me weepThis is no way to run a great nation.

When it comes to predicting snowDC weathermen really don’t knowYet we close schools anywayShut the government for a dayWe're just cold weather wimps, don't you know?

Friday, March 8, 2013

Liberals lost the fight to include a new Medicare-type public option in the Affordable Care Act, but they took some solace in the fact that about half of the people expected to get coverage under ObamaCare would get it through the publically-run Medicaid program. Even though many didn’t like the fact that the other half would get coverage through regulated private insurance sold through exchanges.

But as it is has turned out, even Medicaid—ObamaCare’s last and only true public option--will be replaced in some states with private health insurance, blessed by the Obama administration.

The result will be “a larger, but more conservative” Medicaid program, blogs the Washington Post’s Sarah Kliff. “Emerging deals show [Republican] governors exploring approaches that would significantly reshape the program, such as moving beneficiaries into privately managed health coverage or giving enrollees a greater financial stake in their health care” she writes. And the Obama administration has gone along. For instance, Florida governor Rick Scott was able to get a waiver to move almost all of Florida’s Medicaid enrollees into private health insurance plans, right before announcing his change of heart in favor of expanding the program.

It isn’t just Republican governors, though, pushing for Medicaid privatization. Mike Bebee, the Democratic governor of Arkansas, reached a “super expensive, legally dubious” agreement with the administration to allow the state to “enroll new patients in the same private health plans that will be available for residents with higher incomes, “writes the National Journal’s Margot Sanger-Katz. “If the state Legislature approves the plan, all Arkansans earning below 133 percent of the federal poverty limit—or about $15,000 for a single person—will be able to get [private] health insurance. Other states are watching closely.” (Among them being Texas, where Republican lawmakers recently decided that they opposed expansion—for now—“but left the door open to doing so if the Obama administration grants Texas enough flexibility” reports the Texas Tribune.

On one hand, if you believe in federalism and states as the laboratories of innovation, the willingness of the Obama administration to allow states to privatize Medicaid could be viewed as a good thing, enabling states to achieve ObamaCare’s goal of covering all of the poor and near-poor using customized approaches that may be more suitable to a particular state’s culture and politics. It belies the argument that the Obama administration is trying to impose a one-size-fits-all federal program on states. And if it achieves the goal of getting poor people covered, why should anyone care if a state does it through private insurance instead of the traditional public Medicaid?

Well, you might care if it ends up costing federal taxpayers a lot more. The same National Journal article cited above reports that “Estimates suggest that a plan such as the one proposed in Arkansas may cost in excess of 50 percent more than the Medicaid expansion described by the Affordable Care Act. The cost would increase because private plans that will be sold on state insurance exchanges, or marketplaces, will be much more expensive than government-run insurance and won’t cover all of Medicaid’s required benefits.” And you might care if you believe that private health insurance plans are more likely to skimp on care or take advantage of poor people, and because you are worried that they will divert some of taxpayers’ money to insurance company profit rather than patient care. Yet liberals have for the most part been quiet about Obama administration’s willingness to let states privatize Medicaid, “even though Medicaid is now central to the progressive vision of a universal health care system” writes the Progressive Policy Institute’s Ed Kilgore in this month’s Washington Monthly. “This provides Republicans at the federal and state levels with a dual motive for sabotaging the Medicaid expansion, even if that means that federally run health care exchanges must pick up the slack.”

So here we have it: conservatives have consistently blasted the law and the Obama administration for imposing federally-run health care on the states, yet in fact the Obama administration is allowing conservative states to privatize Medicaid, as long as they agree to expand it to the poor and near-poor. Liberals fought and lost the battle to include a new public option in the Affordable Care Act, yet almost all got behind it in the end because they viewed it as a step toward achieving universal coverage. But how many liberals anticipated that the price they’d pay for getting more people covered would be increasing privatization of Medicaid, the ACA’s only true public option? Yet we are heading to result where more of the poor will end up in private insurance and fewer of them in public Medicaid, leading to “a larger and more conservative Medicaid ”--with relatively little public debate on whether that is the best result for patients.

Today’s questions: What do you think about the growing number of conservative states agreeing to expand Medicaid as long as they can turn it over to private insurance companies? Is this a good or bad thing for patients? And how do you feel about the Obama administration’s willingness to let them?